ID

595

Description

AMC-076 HPV On-Study Form (ONS) Infrared Coagulator Ablation or Observation in Preventing Anal Cancer in HIV-Positive Patients With Anal Neoplasia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A80C062E-17BA-F42E-E040-BB89AD432F38

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A80C062E-17BA-F42E-E040-BB89AD432F38

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 5/20/15 5/20/15 - Martin Dugas
Uploaded on

August 26, 2012

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Anal Cancer NCT01164722 On-Study - AMC-076 HPV On-Study Form (ONS) - 3253321v1.0

English

No Instruction available.

1 forms  
  1. StudyEvent: AMC-076 HPV On-Study Form (ONS)
    1. No Instruction available.
Unnamed1
Description

Unnamed1

Visit number
Description

HospitalAdmissionOrdinalNumber

Data type

double

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16696
UMLS 2011AA ObjectClass
C0019994
NCI Thesaurus Property
C25385
UMLS 2011AA Property
C0809949
Unnamed1
Description

Unnamed1

Date of HIV+ diagnosis (mm/dd/yyyy)
Description

HumanImmunodeficiencyVirusDiagnosisDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C14219
UMLS 2011AA ObjectClass
C0019682
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Date of AIDS diagnosis (mm/dd/yyyy)
Description

AcquiredImmunodeficiencySyndromeDiagnosisDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ObjectClass
C2851
UMLS 2011AA ObjectClass
C0001175
CDC HIV Risk Group
Description

PatientHumanImmunodeficiencyVirusRiskCategory

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C14219
UMLS 2011AA Property
C0019682
NCI Thesaurus Property
C17102
UMLS 2011AA Property
C0035647
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
NCI Thesaurus ValueDomain
C25372
UMLS 2011AA ValueDomain
C0683312
Other, specify
Description

PatientHumanImmunodeficiencyVirusRiskCategorySpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C14219
UMLS 2011AA Property
C0019682
NCI Thesaurus Property
C17102
UMLS 2011AA Property
C0035647
NCI Thesaurus Property
C25161
UMLS 2011AA Property
C0008902
Unnamed2
Description

Unnamed2

History of anal, perianal, or genital condyloma (If "Yes", answer the following)
Description

HumanPapillomavirusDiseaseGenitalAnalCondylomaPersonalMedicalHistoryInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C14226
UMLS 2011AA ObjectClass
C0021344
NCI Thesaurus Property
C13348
UMLS 2011AA Property
C0559522
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property
C4054
UMLS 2011AA Property
C0281779
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
History of penile or genital condyloma
Description

HumanPapillomavirusDiseaseGenitalPenisCondylomaPersonalMedicalHistoryStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C14226
UMLS 2011AA ObjectClass
C0021344
NCI Thesaurus Property
C13348
UMLS 2011AA Property
C0559522
NCI Thesaurus Property
C12409
UMLS 2011AA Property
C0030851
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property
C2960
UMLS 2011AA Property
C0009663
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
History of perianal condyloma
Description

HumanPapillomavirusDiseaseAnalCondylomaSurroundingPersonalMedicalHistoryStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C14226
UMLS 2011AA ObjectClass
C0021344
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property
C52247
UMLS 2011AA Property
C1282914
NCI Thesaurus Property
C4054
UMLS 2011AA Property
C0281779
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
History of intraanal condlyoma
Description

HumanPapillomavirusDiseaseAnalCondylomaInternalPersonalMedicalHistoryStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus ObjectClass
C14226
UMLS 2011AA ObjectClass
C0021344
NCI Thesaurus Property
C25234
UMLS 2011AA Property
C0205102
NCI Thesaurus Property
C18772
UMLS 2011AA Property
C0262926
NCI Thesaurus Property
C4054
UMLS 2011AA Property
C0281779
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
High-grade Dysplasia And Treatment
Description

High-grade Dysplasia And Treatment

Unnamed4
Description

Unnamed4

Lowest CD4+ count ever reported
Description

LaboratoryProcedureCD4+LowestResultCount

Data type

double

Alias
NCI Thesaurus ObjectClass
C25294
UMLS 2011AA ObjectClass
C0022885
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
NCI Thesaurus Property
C12537
UMLS 2011AA Property
C0039215
NCI Thesaurus Property
C43517
UMLS 2011AA Property
C1708760
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Document type
Description

ProtocolDocumentSubmittedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus ObjectClass
C19498
UMLS 2011AA ObjectClass
C1547673
NCI Thesaurus Property
C25695
UMLS 2011AA Property
C1515023
Comments
Description

Comments

Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Back to the top of the page

Similar models

No Instruction available.

1 forms
  1. StudyEvent: AMC-076 HPV On-Study Form (ONS)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
HospitalAdmissionOrdinalNumber
Item
Visit number
double
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25385 (NCI Thesaurus Property)
C0809949 (UMLS 2011AA Property)
Item Group
Unnamed1
HumanImmunodeficiencyVirusDiagnosisDate
Item
Date of HIV+ diagnosis (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C14219 (NCI Thesaurus ObjectClass)
C0019682 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
AcquiredImmunodeficiencySyndromeDiagnosisDate
Item
Date of AIDS diagnosis (mm/dd/yyyy)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C2851 (NCI Thesaurus ObjectClass)
C0001175 (UMLS 2011AA ObjectClass)
Item
CDC HIV Risk Group
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C14219 (NCI Thesaurus Property)
C0019682 (UMLS 2011AA Property)
C17102 (NCI Thesaurus Property)
C0035647 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
CL.1
Code List
CDC HIV Risk Group
CL Item
Homosexual Or Bisexual Contact (Homosexual or bisexual contact)
CL Item
Heterosexual Contact (Heterosexual contact)
CL Item
Iv Drug User (IV drug user)
CL Item
Transfusion Recipient (Transfusion recipient)
CL Item
Hemophilia (Hemophiliac)
C3093 (NCI Thesaurus)
C0684275 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
PatientHumanImmunodeficiencyVirusRiskCategorySpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C14219 (NCI Thesaurus Property)
C0019682 (UMLS 2011AA Property)
C17102 (NCI Thesaurus Property)
C0035647 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
Item Group
Unnamed2
Item
History of anal, perianal, or genital condyloma (If "Yes", answer the following)
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14226 (NCI Thesaurus ObjectClass)
C0021344 (UMLS 2011AA ObjectClass)
C13348 (NCI Thesaurus Property)
C0559522 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C4054 (NCI Thesaurus Property)
C0281779 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.2
Code List
History of anal, perianal, or genital condyloma (If "Yes", answer the following)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
History of penile or genital condyloma
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14226 (NCI Thesaurus ObjectClass)
C0021344 (UMLS 2011AA ObjectClass)
C13348 (NCI Thesaurus Property)
C0559522 (UMLS 2011AA Property)
C12409 (NCI Thesaurus Property)
C0030851 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C2960 (NCI Thesaurus Property)
C0009663 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.3
Code List
History of penile or genital condyloma
CL Item
Yes, Resolved With History Of Treatment (Yes, resolved with history of treatment)
CL Item
Yes, Resolved Without Treatment (Yes, resolved without treatment)
CL Item
Active Genital Condyloma (Active genital condyloma)
CL Item
Active Penile Condyloma (Active penile condyloma)
CL Item
No History (No history)
Item
History of perianal condyloma
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14226 (NCI Thesaurus ObjectClass)
C0021344 (UMLS 2011AA ObjectClass)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C52247 (NCI Thesaurus Property)
C1282914 (UMLS 2011AA Property)
C4054 (NCI Thesaurus Property)
C0281779 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.4
Code List
History of perianal condyloma
CL Item
Yes, Resolved With History Of Treatment (Yes, resolved with history of treatment)
CL Item
Yes, Resolved Without Treatment (Yes, resolved without treatment)
CL Item
Active Perianal Condyloma (Active perianal condyloma)
CL Item
No History (No history)
Item
History of intraanal condlyoma
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14226 (NCI Thesaurus ObjectClass)
C0021344 (UMLS 2011AA ObjectClass)
C25234 (NCI Thesaurus Property)
C0205102 (UMLS 2011AA Property)
C18772 (NCI Thesaurus Property)
C0262926 (UMLS 2011AA Property)
C4054 (NCI Thesaurus Property)
C0281779 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.5
Code List
History of intraanal condlyoma
CL Item
Yes, Resolved With History Of Treatment (Yes, resolved with history of treatment)
CL Item
Yes, Resolved Without Treatment (Yes, resolved without treatment)
CL Item
Active Intraanal Condyloma (Active intraanal condyloma)
CL Item
No History (No history)
Item Group
High-grade Dysplasia And Treatment
Item Group
Unnamed4
LaboratoryProcedureCD4+LowestResultCount
Item
Lowest CD4+ count ever reported
double
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C12537 (NCI Thesaurus Property)
C0039215 (UMLS 2011AA Property)
C43517 (NCI Thesaurus Property)
C1708760 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item
Document type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C19498 (NCI Thesaurus ObjectClass)
C1547673 (UMLS 2011AA ObjectClass)
C25695 (NCI Thesaurus Property)
C1515023 (UMLS 2011AA Property)
CL.6
Code List
Document type
CL Item
Lab Report (Lab Report)
CL Item
Physician/provider Report Or Clinical Note (Physician/provider report or clinical note)
CL Item
Subject Recall (Subject recall)
Item Group
Comments
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial